Injuries in Weekend Warriors to Professional Athletes: How Demographics Affects Medical Care SHAUN A. NOTMAN, D.O.

SPORTS MEDICINE FELLOW

LARKIN COMMUNITY HOSPITAL

SHAUN.NOTMAN@GMAIL.COM

Disclosures • No relevant financial relationships

• No off label usage

Learning Objectives • Evaluate and treat common conditions associated with

sports/physical activity

• Screen and treat specific populations for injuries sustained in sports/physical activity

• Understand the basis for injury prevention utilizing general conditioning and sports specific conditioning

• Guidelines for pediatric sports/play intensity and longevity

Demographics • Pediatrics

• Geriatrics

• Male

• Female

• Pregnant

• Disabled

Types of Activities • Professional Organized Sports • Almost always requiring discipline, commitment, and training

• Amateur Organized Sports • Frequently requiring discipline, commitment, and training

• Can include those with little activity specific conditioning

• Group/Individual Organized Events • Weekend/Evening leagues (softball, bowling)

• Weekend Races/Events/Obstacle courses (FASTEST GROWING IN US) • Professionals, amateurs, and lay people participate side by side

• Open entry, no requirement of previous participation/training

• Individual Unorganized Events • Solo exercise

• Solo sports (running, cycling)

Conditioned vs Unconditioned • Body adaptation to Metabolic, Neuromuscular, and Psychologic

demands of activity with conditioned activity

• Sports Specific vs. Non-Sport Specific Conditioning/Training

• Training progression over reasonable amount of time

• Strength and Endurance AND FLEXIBILITY

• Effects on MSK Injury Recovery if unconditioned • Lower stress threshold for initial injury

• Delayed vascularity and inflammatory response

• Delayed early immobilization/weight bearing

• Decreased threshold for re-injury despite adequate rehabilitation

Activity Enhancements • Doping seen in professional athletes • World Anti-Doping Agency (WADA) and United States Anti-Doping Agency

• List of banned substances globalDRO.com

• Prohibited at all times • Anabolic Agents (ex: Stanozolol, EPO)

• Beta-2 agonists (ex: Albuterol)

• Stimulants (ex: Amphetamines, Psuedoephedrine)

• Hormone Therapy

• Diuretics (ex: Lasix, HCTZ)

• Insulin

• Prohibited in during Competitive Window • Narcotics/Opioids (except codeine)

• Cannabinoids (whether psychoactive or not)

• Corticosteroids

• You might be asked to sign Therapeutic Use Exemption for common but prohibited meds

Activity Enhancements • Performance Enhancement seen in recreational athletes (often less

aware of possible side effects/consequences) • Stimulants • Caffeine

• ENERGY DRINKS

• Amphetamines

• Psuedoephedrine

• Hormones • Testosterone

• HCG

• Cannabis

• Alcohol

• Albuterol

• Increasing doses of prescribed medication • Anxiolytics

• Narcotics/Opioids

Sports Medicine Pharmacology • Analgesics • Acetaminophen

• NSAIDs

• Opioids (Underuse vs Overuse, Medical vs Legal)

• Corticosteroids (intraarticular injection 48 hour rule?)

• Not Aspirin (narrow therapeutic window)

• Antibiotics • Does the patient really need it?

• Avoid Flouroquinolones generally, especially with concomitant steroid use (cumulative effect? Age a concern if over 50?), Prolonged QT

• Anti-hypertensives • If subject to testing, first line includes ACE, ARB, CCB

Common Injuries and Medical Issues • Exacerbation of underlying

medical conditions

• Muscle Strain

• Ligamentous Sprain

• Tendonitis/tenosynovitis

• Fracture/Dislocation

• Patella-femoral Syndrome

• Contusion

• Disc Injury

• Lacerations, Abrasions, Hematomas

• “Stingers” or “Burners”

• Headache

• Heat Stroke/Exhaustion

• Exercise Induced Hematuria (Athletic Psuedonephritis/Sports Hematuria)

• Exercise Induced Proteinuria

• Exertional Rhabdomyolisis

• Exertional Compartment Syndrome

Pediatric Athletes • Childhood obesity is a growing problem in the US, and has tripled

since the 1970s and nearly 1 in 5 children is obese

• Only about 20% of High School seniors reports vigorous exercise, representing a major gradual reduction over last 40 years

• Roughly 50% in organized sports in school or community, and 50% independent activities

• Despite decrease in activity, athletic and MSK injuries are increasing

• Playing through fatigue or pain is not appropriate for skeletally immature individuals

• OVERUSE injuries much more common than acute injury

• Contralateral films very useful

Pediatric Athletes • Potential for delayed recovery from concussion, or require longer

periods of cognitive rest

• Growth-Plate and Growth-Site Injuries

• Muscle Strains and Contusions are MC pediatric athlete injuries

• Fractures, SCFE, Apophysitis/Epiphysitis, Osteochondritis Dissecans, Osteonecrosis

• Injury Equivalents

• ACL rupture – Tibial Spine avulsion

• Lumbar Strain – Spondylosis

• Severe Low Back Pain – Spondylolisthesis

• UCL tear – Medial epicondyle Apophysitis/Epiphysitis

• Patellar Tendonitis – Osgood-Schlatter

• Hip Strain – Avulsion Fracture

Pediatric Athletes • Orthopedic Surgeons are seeing degenerative changes that was

typically seen in professional athletes in their mid to late 20’s in the ABSENCE of traumatic events

• Growing structures more susceptible to stress

• Increase in strength and performance typically from neuromuscular adaptation and proficiency, rather than muscle hypertrophy until puberty

• Sport with most injuries for boys – Football

• Sport with most injuries for girls – Soccer

• Nutrition and proper hydration must be maintained with any activity

Pediatric Athletes • Recommendations - All sports with kids must • Be at the level that closely matches their ability

• Should be supervised

• Proper protective equipment should be sized at beginning and middle of season to accommodate for growth/body changes

• Training programs should progress slowly and at the proper intensity to avoid injury

• 1-2 days a week and 2-3 months a year not engaging in sport, or competing in mechanically different sport

• 10 years

• 15 years

• Skeletal maturity 18-24

Pediatric Athletes • Osteopathic Manipulative Treatment • Benefit well from soft tissue techniques addressing stress/tension

imbalance

• Great treatment for injury prevention or reducing likelihood of injury progression

• Techniques include • Myofascial Release

• Muscle Energy

• Balanced Ligamentous Technique

• Ligamentous Articular Strain

Geriatric Athletes • Decreased muscle mass, strength, and function roughly 20% by age

65

• Decreased endurance and flexibility also roughly 20% by age 65

• Balance and coordination can be affected by nutritional deficiency in diet, inactivity, deconditioning, medical illness

• Injury recover often takes longer

• Especially susceptible to dehydration and heat illness

• Exercise can often delay the decrease of these components of health

Geriatric Athletes • Exercise can delay and to a large degree prevent onset of dementia

• Exercise in populations with dementia showed improved neurocognitive testing, better function, and decreased degree of assistance

• Aerobic exercise 3-5 times a week may directly counteract decreasing vascular compliance associated with aging

• Encourage Canoeing, Hiking, Road bicycling, Rowing, Speed walking, Swimming, Tennis, Weight machines/resistance training

Geriatric Athletes • Most common complaints preventing exercise • Short of Breath

• Weakness

• Knee Pain

• Back Pain

• Maintaining muscle strength and cardio conditioning in middle age

• Addressing degenerative OA with oral/injectable meds • Steroid or Viscosupplementation – low risk, low to high yield results

(patient specific)

• Physical therapy, Osteopathic Manipulation, Neuromuscular therapy

Geriatric Athletes • Osteopathic Manipulative Treatment • Techniques should focus on maintaining maximum range of motion, as well

as specific somatic dysfunctions identified

• Great treatment for injury prevention or reducing likelihood of injury progression

• Techniques include • Counterstrain

• Still’s Techniques

• Facilitated Positional Release

• Myofascial Release

• Muscle Energy

Female Athletes • Female Athlete Triad (under diagnosed, poor screening) • Energy deficiency with or without eating disorder

• Menstrual disturbances/Amenorrhea

• Bone loss/Osteoporosis/Abnormal bone quality

• Secondary Amenorrhea can be must disruptive - Seen in nearly 70% of dancers and 65% of long distance runners

• Disordered eating – up to 10% of gen pop, as high as 65% in certain sports (Gymnastics)

• BMD deficiency can be as high as 20% in female athletes

• Amenorrhea sometimes seen as a training goal

• These athletes may present for something else (wrist pain, snapping hip), we must screen for Triad

• Multi-Disciplinary approach – Nutrition, Psychological, Medical, OB/GYN, Sports

• MVI/Supplements, CBT, OCP, Possible SSRI

Female Athletes • ACL Rupture • 2x – 10x ACL tear incidence depending on sport (non-contact > contact)

• Pivoting, cutting, rapid deceleration

• Decreases hip/knee flexion with landing from height

• Increased femur IR, knee valgus, and imbalance favoring quad over hamstring (ant tib translation); small intercondylar notch window with small ACL (on average)

• Some suggestion in lit about hormonal changes causing risk, not well supported

• ACL Prevention/Reeducation program for sport specific drills and overall strengthening and imbalance correction

Female Athletes • Older, multi-parous – pelvic floor dysfunction, incontinence

• Stress incontinence (40-50% women engaged in sport) • Timed voiding, scheduled fluid intake, Kegel exercises

• Urge Incontinence (15-20% women engaged in sport) • Bladder training, Antimuscarinics

Female Athletes • Pregnant Athlete • Encourage exercise and CV activity

• Maintain CV health, less weight gain, less abd/pelvic/back pain, less risk of depression and gestational diabetes

• Moderately strenuous activity 4-5 days a week, HR at 70-80% max

• Fetal benefits seen in neurobehavioral development, healthy (low to mid range) birth weight

• Previously inactive women should be encouraged to very slowly and gradually increase activity under supervision

• Absolute Contraindications to exercise in pregnancy • Heart Disease, Restrictive lung disease, incompetent cervix, 2nd/3rd trimester bleeding,

ruptured membranes, premature labor, preeclampsia

• Symptoms – dyspnea, headache, chest pain, contractions, vaginal bleeding

Female Athletes • Osteopathic Manipulative Treatment • Techniques addressing female demands specifically center around pregnant

female

• Assistance with pain associated with stretch receptor activation in pelvic and abdominal tissues

• OMT in pregnancy associated with decreases in use of assisted device for delivery, length of labor, blood pressure, low back pain, SI dysfunction

• Techniques include • Counterstrain

• Ligamentous Articular Strain

• Still’s Techniques

• Myofascial Release

Male Athletes • Testicular Trauma • Torsion, Rupture, Hematoma

• Pain and nausea

• Rupture might be indicated if no transillumination, or normal palpable structures

• Penetrating trauma must address infection and tetanus

• Scrotal US • low severity treated with ice, rest, analgesia

• Torsion (younger pts) – infacrtion/tissue death in as little as 6 hours. Surgical emergency

• Single functional testicle – Contact sports contraindicated, patient must wear protective cup and use caution

Male Athletes • Inguinal Hernia vs Sports Hernia • Inguinal hernia with herniation of abdominal contents into defect which

require surgical repair for definitive treatment when needed:

• Direct - abdominal wall (Hesselbach's triangle)

• Indirect - internal inguinal ring

• Femoral – femoral ring

• Sports Hernia (Athletica Pubalgia) • Misnomer – refers to groin pain in absence of diagnosed indirect, direct, or

indirect hernia

• “Result from chronic, repetitive trauma or stress to the musculotendinous portions of the groin” – UpToDate

• Rarely sudden onset, usually overuse of lower abdominal or upper thigh structures.

Disabled Athletes • Intellectual and Physical • Physical impairment has 10 subcategories

• Injury rates are very similar between disabled athlete and those without disability in summer and winter sports.

• Paralympic infrastructure has surged since 2000

Disabled Athletes • Wheelchair Athletes • Median and Ulnar Nerve entrapments, Shoulder overuse injuries

• Spinal Cord Injuries • Autonimic dysregulation, Orthostatic hypotension, Incontinence, Muscle

tone/spasticity

• Vision loss • No contact sports, Projectile sports with adequate protection, Impaired

depth/proprioception affects reaction time, driving sports

Disabled Athletes • Down Syndrome (does not imply disabled, but frequently

biomechanically abnormal with changes in gait, coordination, locomotion)

• Atlanto-Axial Instability in 10-20%, 1-2% symptomatic • Symptomatic – No sports, consider surgical eval

• Asymptomatic – Sport restriction (gymnastics, cheerleading, power lifting, skiing, diving, football)

• Cervical X-ray will show >3-4mm Atlanto-odontoid distance

• Absolute contraindication for HVLA of that segment

Disabled Athletes • Osteopathic Manipulative Treatment • Techniques addressing specific musculoskeletal deviations from typical

anatomy, or changes in common compensatory pattern matching patient specific changes in gait/locomotion

• Techniques include • Counterstrain

• Ligamentous Articular Strain

• Still’s Techniques

• Myofascial Release

• Balanced Ligamentous Technique

• Facilitated Positional Release

• High Velocity, Low Amplitude

• Muscle Energy

Selected References • Adirim TA: Overview of injuries in the young athlete. Sports Medicine 2003; 33(1): 75-81.

• Ali FE, Al-Bustan MA, Al-Busairi WA, Al-Mulla FA, Esbaita EY. Cervical spine abnormalities associated with Down syndrome. Int Orthop. 2006;30:284–289.

• Arendt E., Dick R.: Knee injury patterns among men and women in collegiate basketball and soccer: NCAA data and review of literature. Am J Sports Med 23. 694-701.1995.

• Baker RJ, Patel D. Lower back pain in the athlete: Common conditions and treatment. Prim Care. 2005;32(1):201–229.

• Brukner P, Khan K. Brukner & Khan’s Clinical Sports Medicine. Sydney, Australia: McGraw-Hill Book Company Australia; 2011. p. 463-491.

• https://www.cdc.gov/healthyschools/obesity/facts.htm

• Injuries to Athlete with Disabilities. Identifying injury patterns – Ferrara, Sports Med 2000 Aug; 30(2): 137-143

• King HH, Tettambel MA, Lockwood MD, Johnson KH, Arsenault DA, Quist R. Osteopathic manipulative treatment in prenatal care: a retrospective case control design study. J Am Osteopath Assoc. 2003;103(12):577-582.

• Licciardone JC, Buchanan S, Hensel KL, King HH, Fuld KG, Stoll ST. Osteopathic manipulative treatment of back pain and related symptoms during pregnancy: a randomized controlled trial. Am J Obstet Gynecol. 2010;202(1):43.

• Nelson KE, Glonek T. Somatic Dysfunction in Osteopathic Family Medicine. New York, NY: Lippincott Williams & Wilkins; 2006:108-113.

• Osteopathic Manipulative Treatment in Pregnant Women. Lavelle JM et al. J Am Osteopath Assoc. 2012 Jun;112(6):343-6.

• U.S. Department of Health and Human Services. Physical Activity Guidelines Advisory Committee report. Washington, DC: U.S. Department of Health and Human Services, 2008.

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